8709 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECTI DENTI FICATION PERMIT NUMBER
BUILDING APPLICATION & PERMIT 8709
X ADDRESS ( 1�y
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL
OWNER'$
NAME PLAN CHECK VALIDATION
• ^ .�- ^1/ t • 2-S-1-670'
OTY. ELECTRIC PERMIT FEE
(j�AJ"µJL�/�. J'". HE �S Z'676
XCONTRACTORS
NAME//���� J,, /�. t, OUTLETS-SWITCHES-RECEP 10.00/1.00
FSI 'at✓VM405 uc NO. L�L86 V LIGHTING FIXTURES 10.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00
' taDDRE$$ � t �B))
t. 30f m VIS PHONE 2-C-6 �1 PANELS 1940 GATE OF APPLICATION
OORRCHIrIECT PANELS (OVER 200 AMP) 20.00 PLAN CHECK FEE P.C.NO.
ENGINEER
LIC NO. SIGNS TRANS. 3.00
aoo Ess ENG. SPECIAL CIRCUIT S.QQ PERMIT VALIDATION
ZIP TEMP.METER OR POLE S. 20.00
ADDRESS - MOTORS SEE FEE SCH.
1. aooREs
SERVICE CHA 20.00
, 00 LICENSED CON'PRACTORS DECLARATION TEMP.POLV 30.00
a u w I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
m < h (commencing with Section 7000)of Division 3 of the Rpsinca and BLDG. ELECT. P G. MECH.
F w t Professions Codc,anA ny licmac is in full force and ellen.
o i m o� License Class _Lic.Num M1cr�.,.�_ (ly_ El EEJ
H m H SO/ Date Contractor /�/
BUILDING PERMIT
a
OWNER-BUILDER UECLA RA ON
o a sa MISC.- REFER TO ORD INFORMATION
w S u H I hereby affirm that 1 am exempt from the Contractors License
u_o J Law for the following reason.(Sec.7031.5,Bhsinessand Professions PERMIT ISSUANCE 10.00 VALUATION 5/FT.
Code:Any city or county which requiresa permit lomretruct.alter,
aQ a improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELE
wD e regmre5 the applicant for such permit to IIIc a signed statement that TOTAL PERMIT TO
m m he is licensed pursuant to the provisions of the Contractor's License
Hz >
Law(Chapter 9(commencing with Section 7000)oCOivision 3 ofthc
a Business and professions Code)or that Ite is exempt therefrom and QTY. PLUMBING PERMIT FEE
Fio
v: H Ih!basis for the alleged exe in p ion.Any viola t io It of Section 7031.5 ST RIE TV E CONSTR.
A. by any applicant for a permit subjects the applicant to a civil penalty ALTER-DRAIN&VENT-WATER (EA.) 5.00
of not more than five hundred dollars($500)):
❑ I,as owrero.f the property,or myemployees with wages as BACK F LOW PROTECT. DEV ICE 4.00 OCC.GROUP RES.UNITS
their sole compensation;will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 5.00 50.FT.FLOOR AREA TOTAL ACREAGE
inenelfor of ugh Intended
ownemployees.for sale.
if,h ever.hat the building
GAS-EA.SYSTEM-l 6.00
mems are not intended or offered for sale.If,however.the bus Wing
or improvement is sold within one year of completion,the owner-
builderwill have the lindale.) of proving that he did nal build or int- RES IND CON PB 'Omer
prove 1,as owner
off t le), INDUSTRIAL WASTE INTER. 30.00
❑ d as owner of the property,he exclusively contracting with ❑ 0 El
licensed contractors od : construct the project La 7044,Business LAWN SPRINKLERS- 1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to incontracts
owner of property who builds tr improvesthereon,p,and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
the Con for such License
projects with a contmctortsl license)pursuant to
the Contractor's Lirense Law. SEWER-SANITARY-STORM EA.200ft/10.00 _ - TRACT NO. PARCEL NO.
❑ lam exempt under Sec.-,B&P.C.for this WATER HEATER W/VENT 6,00
reason
Owner Date WATER SYSTEM 5.00 ACC.OATE ACC,FILE NO.
WORK ERS'C'OMPENSATION DECLARATION WATER TREATING EQUIP. 5.00
I hereby affirm that 1 Lova a certificate of consenl to pelf-insure, ZONING ENG.SITE N0.
or a certificate of Workers Compensation Insurance,or a certified
copy thereof(See.3800,Lab.C.).
Policy No. Company
O ❑ Certified copyis hereby l commed FIRE SPRINK ENERGY T-24
Z Z O Certified c 0led lh Ie city inspection division.
ff Q�- -4 ,a ' MISC.- REFER TO ORO.
O'\ Applicant V N V N
~ m PERMIT ISSUANCE 10.00
� - CERTIFICATE OP IiX1iMPIT FROM WORKERS' FLOOD ZONE A.L.U.C.
LU 7 COhIPENSAiION INSURANCE PLG.CONTE. LIC.NO, PLG.
CL Z [this section need mol he completed if the permit is for one TOTAL J V N� V NC]
hundred dollars IS 100)or less.)
U O 1 certify than In the pertormunce of the work for which this per- CITY. MECHANICAL PERMIT FEE FEE SUMMARY
H pint it is issued,I shall not employ any person in any manner so us to
O U become subject to the Workers Compensation Laws of California.
Q_ Dale Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE TO APPLICANT: If,after making this Certificate of Ex-
Z enlption,you should become subject to the Worken'Compensation APPLIANCE 5.00 PLAN CHECK
Provisions of the Labor Code, You most forthwith comply with FEE
U such provisions or this permit shall be deemed revoked. AIR HANDLING UNIT(TO 10=C.F.M.)
CONSTRUCTION LERDING AGENCY AIR HANDLING UNIT(OVER 10=C.F, 6.00 SEISMIC FEE
I hereby affirm than there is a construction lending agency for EXHAUST HOOD (WITH DUCTP., 5.00
the penerriance of the work for which this permit is issued(Scc. MICROFILM
30'97,Cie C.). HEATING UNIT(TO 100, B.T.U.) 800
Lender's Name HEATING UNIT(OV Q0,000 B.T.U.)9.50
Lender's Address ELECTRIC
I certify that I have read this application and stale than the above VENTILATION F (SINGLE) 4.00
information is correct.I agree to comply with all city and county PLUMBING
ordinances and state laws relating m building construction, and BOILER- H.P-Dr100,000B.T.U.) 6.00
hereby' authorize representatives of this city to enter upon the gQILE MP(❑ver t00000BTU)SEE FEE SCH. MECHANICAL
above-mentioned property for inspection purposes.
(We) agree to save, indenmify and keep harmless the City of M 122L REFER TO ORD.
Cupertino against liabilities,judgments, costs and expenses which RMIT ISSUANCE 10.00 CONST.TAX
may in any way accrue against said City in Consequcn ce oC the
granting f this rust M; .CONT. LIC.NO. MECH.
-` TOTAL TOTAL
Signal o p I ant/Coltracnor Dat!
INSPECTOR COPY